VIP Call Girl Sector 88 Gurgaon Delhi Just Call Me 9899900591
SC.pptx
1.
2. Stabilization Centre (SC)
SC provides treatment for children 6 to 59 months
who are severely acutely malnourished who do not
have an appetite and/or have medical complications
Average length of stay in SC is 4-7 days
24 hour care
Skilled personnel who have received the
appropriate training
SAM Infants (less than 6 months) or are unable to
breast feed also require specialized treatment in SC
3. Purpose of SC
For children 6 to 59 months without appetite or with
medical complications:
To stabilize any medical complications so that the child
can start nutritional rehabilitation
For infants less than 6 months:
For breast-fed infants: To feed the infant and stimulate
breast-feeding until the infant can be fed
For non-breast-fed infants: To nutritionally rehabilitate
the infant.
4. Admission criteria for SC
Category Criteria
Children
6-59 months
Any of the following:
Bilateral pittingoedema+++
or
Marasmic-Kwashiorkor ( = W/H < -3 S
D or MUAC <115mm with any
grade of oedema)
Or
MUAC <115mm or W/H < -3 S
D or bilateral oedema+ / ++
WITH any of the following complications
Anorexia, no appetite for RUTF
Vomits everything
Hypothermia≤35.5 °c
Fever ≥38.5 °c
S
evere pneumonia
S
evere dehydration
S
evere anaemia
Not alert (very weak, lethargic, unconscious, fits or convulsions)
Conditions requiringIV infusion or NG tube feeding
Infants < 6 months Infant is too weak or feeble to suckle effectively (independently of
his/her weight-for-length).
W/L (weight-for-length ) < - 3 S
D (in infants > 45 cm)
Visible severe wastingin infants < 45 cm
Presence of bilateral oedema
Other reasonsfor inpatient enrolment
Readmission Children previously discharged from in-patient care but meets inpatient
care enrolment criteriaagain
Return after default Children who return after default (away from in-patient care for 2
consecutive days) if they meet the admission criteria
5. Exit criteria for SC
Category Criteria
Discharge to OTP There are no medical complications
Appetite has returned (the child has taken at least 75% of
the prescribed RUTF ration for at least 2 consecutive
days)
Oedema is resolving
Discharge when
there is no OTP
Oedema
Oedema is absent for 2
consecutive days
is weight gain for 2
consecutive days after
loss of oedema
Child is taking at least
90% of the RUTF
There are no medical
complications
No oedema
Weight gain for 5
consecutive days
Child is taking at least
90% of the RUTF
There are no medical
complications
Died Child died while in in-patient care
Defaulter Child is absent from in-patient care for 2 consecutive days
Medical referral
out of programme
Where the medical condition of the child requires referral out of
in-patient care e.g. to referral hospital
6. Guidelines for the inpatient treatment of
severely malnourished children
A. General principles for routine care (the ‘10 Steps’)
B. Emergency treatment of shock and severe anemia
C. Treatment of associated conditions
D. Failure to respond to treatment
E. Discharge before recovery is complete
7. A. General principles for routine care
(the ‘10 Steps’) 10
Step 1. Treat/prevent hypoglycemia
Step 2. Treat/prevent hypothermia
Step 3. Treat/prevent dehydration
Step 4. Correct electrolyte imbalance
Step 5. Treat/prevent infection
Step 6. Correct micronutrient deficiencies
Step 7. Start cautious feeding
Step 8. Achieve catch-up growth
Step 9. Provide sensory stimulation and emotional support
Step 10. Prepare for follow-up after recovery
8. An initial stabilization phase
where the acute medical conditions are managed;
and a longer rehabilitation phase.
9. Step 1. Treat/prevent hypoglycemia
Hypoglycemia and hypothermia usually occur together and are
signs of infection.
• Check for hypoglycemia whenever hypothermia (axillary <35.0C) is
found
• Frequent feeding is important in preventing both conditions.
10. Treatment:
If the child is conscious and dextrostix shows <3mmol/l or
54mg/dl give:
• 50 ml bolus of 10% glucose or sugar water ( orally or by nasogastric
(NG) tube.
• Then feed starter F-75 every 30 min. for two hours
(giving one quarter of the two-hourly feed each time)
• antibiotics
• two-hourly feeds, day and night
11. Treatment:
If the child is unconscious, lethargic or convulsing give:
• IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose or sugar
water by Ng tube.
Then give starter F-75 every 30 min. for two hours
(giving one quarter of the two-hourly feed each time)
• antibiotics
• two-hourly feeds, day and night
12. Monitoring:
Blood glucose:
-if this was low, repeat dextrostix taking blood from finger or
heel, after two hours. Once treated, most children
stabilize within 30 min.
-If blood glucose falls to <3 mmol/ l give a further 50ml bolus of 10%
glucose or sugar water, and continue feeding
every 30 min. until stable
-level of consciousness: if this deteriorates, repeat dextrostix
13. Prevention:
Feed two-hourly, start straightaway or if necessary,rehydrate
first. Always give feeds throughout the night
Note: If you are unable to test the blood glucose level, assume
all severely malnourished children are hypoglycemic
and treat accordingly.
Sugar Water: Add two teaspoonful of sugar in 100ml of clean
drinking water
14. Step 2. Treat/prevent hypothermia
Treatment:
If the axillary temperature is <35 °C.
feed straightaway (or start rehydration if needed)
rewarm the child: either clothe the child (including head),
cover with a warmed blanket and place a heater or lamp nearby
(do not use a hot water bottle), or put the child on the
mother’s bare chest (skin to skin) and cover them
give antibiotics
15. Step 2. Treat/prevent hypothermia
Monitor:
body temperature: during rewarming take temperature
two hourly until it rises to >37.oC (take half-hourly if heater
is used)
ensure the child is covered at all times, especially at night
16. Step 2. Treat/prevent hypothermia
Prevention:
feed two-hourly, start straightaway
always give feeds throughout the day and night
keep covered and away from draughts
keep the child dry, change wet nappies, clothes and bedding
avoid exposure (e.g. bathing, prolonged medical examinations)
let child sleep with mother at night for warmth
17. Step 3. Treat/prevent dehydration
Note: Low blood volume can coexist with edema. Do not use the IV route
for rehydration except in cases of shock and then do so with care,
infusing slowly to avoid flooding the circulation and overloading
the heart
18. Diagnosis
Clinical signs of some and severe dehydration
Signs Some Severe
Recent frequent watery diarrhoea Yes, > 3 times a day Yes, profuse
Recent sunken eyes Yes Yes
Recent rapid weight loss 1-5 % 5-10%
Thirst Drinks eagerly Drinks poorly
Absence of tears No Yes
Weak/absent radial pulse No Yes
Cold hands or feet No Yes
Mental state Restless and irritable Lethargic/coma
Urinary output Decreased Absent
19. DEHYDRATION / REHYDRATION
In Malnourished Children
All the signs of dehydration in a normal child occur in a severely malnourished
child who is not dehydrated – only history of fluid loss and very recent change
in appearance can be used
Giving a malnourished child who is not really dehydrated treatment of
dehydration is very dangerous
Misdiagnosis of dehydration and giving inappropriate treatment is the commonest
cause of death in severe malnutrition
The treatment of dehydration is different in the severely malnourished child
from the normally nourished child
20. DEHYDRATION / REHYDRATION
In Malnourished Children
Infusion are almost never used and are particularly dangerous
ReSoMal must not be freely available in the unit – but only taken when
prescribed
The management is based mainly on accurately monitoring changes in weight
Severely wasted patients cannot excrete excess sodium and retain it in their body.
This leads to volume overload and compromise cardiovascular system. The
resulting heart failure can be very acute (sudden death) or be misdiagnosed as
pneumonia
21. Diagnosis
History of recent changes in appearance of eyes
History of recent fluid loss
Check the eyes lids to see if there is lid-retraction.
Check if patient is unconscious or not
Check if patient has recently lost weight (if in SC)
22. Dehydration , septic shock
and hypoglycaemia
If there is a history of recent watery diarrhoea and recent change in the
appearance of the eyes usually with the retraction of eyelid then treat the child for
dehydration.
If this history and signs are not present, the child appears to be dehydrated
without a history of excess fluid loss or child has oedema then consider treating
for septic shock.
23. Dehydration , septic shock
and hypoglycaemia
Signs of shock present:
No history of major fluid loss
No history of recent eyes sinking
Fast weak pulse, cold peripheries, pallor and drowsiness
Eyelid drooping/normal or closed when asleep/unconscious
Septic shock
Eyelid retracted or slightly open when asleep/unconscious
Septic shock + hypoglycaemia
24. Oral Treatment of Dehydration
The main complications of diarrhoea are dehydration, hypovolaemic shock and
congestive heart failure due to over-hydration as a result of the treatment.
Severely malnourished children are very sensitive to overloading the system with
fluids and electrolytes.
Therefore no ReSoMal (REhydration SOlution for MALnourished) or ORS
is given to prevent dehydration.
ReSoMal is only given when dehydration is diagnosed.
25. ReSoMal
ReSoMal = Rehydration Solution for Severe Malnourished patients
Presentation
- Sachet containing 84 g of powder, to be diluted in 2 liters of clean, boiled and cooled
water for treatment of 3 children
- Sachet containing 420 g of powder, to be diluted in 10 liters of clean, boiled and cooled
water for treatment of 15 children
Composition for one liter
Glucose 55 mmol Citrate 7 mmol
Saccharose 73 mmol Magnesium 3 mmol
Sodium 45 mmol Zinc 0.3 mmol
Potassium 40 mmol Copper 0.045 mmol
Chloride 70 mmol
Osmolarity 294 meq /liter
26. Oral rehydration with ReSoMal for severe Malnourished
During the first 2 hrs During the next 10 hrs Total over 12 hrs
Weight
in kg
5 ml/kg
every 30 minutes
Total over 2 hrs
20 ml/kg
5 ml/kg
every hour
Total over 10 hrs
50 ml/kg
70 ml/kg
3 15 ml every 30 min 60 ml 15 ml every hour 150 ml 210 ml
4 20 ml every 30 min 80 ml 20 ml every hour 200 ml 280 ml
5 25 ml every 30 min 100 ml 25 ml every hour 250 ml 350 ml
6 30 ml every 30 min 120 ml 30 ml every hour 300 ml 420 ml
7 35 ml every 30 min 140 ml 35 ml every hour 350 ml 490 ml
8
40 ml every 30 min
160 ml
40 ml every hour
400 ml 560 ml
9
45 ml every 30 min
180 ml
45 ml every hour
450 ml 630 ml
10
50 ml every 30 min 200 ml 50 ml every hour
500 ml 700 ml
27. Alternative recipes in the absence of ReSoMal
Solutions can be made by using one of the following types of
rehydration salts:
· Standard WHO-ORS (sachet containing 3.5 g of sodium chloride, 1.5 g
of potassium chloride, 20 g of glucose, total weigh: 27.9 g per sachet)
*
CMV® mineral and vitamin complex: 1 measure = 6,5 grams.
Water Standard WHO-ORS Sugar CMV*
2 liters 1 sachet 50 g 1 measure
10 liters 5 sachets 250 g 5 measures
28. Step 4. Correct electrolyte imbalance
All severely malnourished children have excess body sodium even though plasma
sodium may be low (giving high sodium loads will kill). Deficiencies of
potassium and magnesium are also present and may take at least two weeks to
correct. Edema is partly due to these imbalances. Do NOT treat edema with a
diuretic.
29. Step 5. Treat/prevent infection
In severe malnutrition the usual signs of infection, such as fever, are often absent,
and infections are often hidden.
Therefore give routinely on admission:
-broad-spectrum antibiotic (s) AND
measles vaccine if child is > 6m and not immunized (delay if the child is in
shock)
31. Step 6. Correct micronutrient deficiencies
No need of supplementation while using Therapeutic feed but Vitamin A is
recommended to all malnourish children except patient with edema.
Some authorities recommend Folic acid at admission.
32. Step 7. Start cautious feeding
Monitor and note:
• amounts offered and left over
• vomiting
• frequency of watery stool
• daily body weight
33. Weighing chart for F75
To 100ml Add 20.5g
To 250ml Add 50g
To 500ml Add 100g
To 1000ml Add 205g
You can make up 2 feeding at 1 time BUT divide the mix into 2 jugs and store the
second feed separately in the fridge.
Ensure the open bag of powder is sealed again properly to stop contamination
34. Step 8. Achieve catch-up growth
In the rehabilitation phase a vigorous approach to feeding is required to achieve
very high intakes and rapid weight gain of >10 g gain/kg/d.
The recommended milk-based F-100 contains 100 kcal and 2.9 g protein/100 ml
35. Monitor during the transition for signs of heart failure:
respiratory rate
pulse rate
If respirations increase by 5 or more breaths/min and pulse by 25 or more beats/min
for two successive 4-hourly readings, reduce the volume per feed (give 4-hourly F-100
at 16 ml/kg/feed for 24 hours,
then 19 ml/kg/feed for 24 hours, then 22 ml/kg/feed for 48 hours, then increase each
feed by 10 ml as above).
After the transition give:
frequent feeds (at least 4-hourly) of unlimited amounts of a catchup formula 150-220
kcal/kg/d
36. Monitor progress after the transition by assessing the rate of
weight gain:
• weigh child each morning before feeding. Plot weight
• each week calculate and record weight gain as g/kg/day
If weight gain is:
• poor (<5 g/kg/d), child requires full reassessment
• moderate (5-10 g/kg/d), check whether intake targets are being met,or
if infection has been overlooked
• good (>10 g/kg/d), continue to praise staff and mothers
37. Step 9. Provide sensory stimulation
and emotional support
In severe malnutrition there is delayed mental and behavioral
development.
Provide:
• tender loving care
• a cheerful, stimulating environment
• structured play therapy 15-30 min/d
• physical activity as soon as the child is well enough
• maternal involvement when possible (e.g. comforting, feeding,
bathing,play)
38. Step 10. Prepare for follow-up after recovery
A child who is 85% weight-for-length (equivalent to -1SD) can be
considered to have recovered (TFC). The child is still likely to have a
low weight-for-age because of stunting. Good feeding practices and
sensory stimulation should be continued at home.
Show parent how to:
• feed frequently with energy- and nutrient-dense foods
• give structured play therapy
Advise parent to
-bring child back for regular follow-up checks
-ensure booster immunizations are given
-ensure vitamin A is given every six months
40. B. EMERGENCY TREATMENT OF SHOCK
Shock from dehydration and sepsis are likely to coexist in severely
malnourished children. They are difficult to differentiate on clinical signs
alone.
Children with dehydration will respond to IV fluids. Those with septic shock
and no dehydration will not respond.
The amount of fluid given is determined by the child’s response.
Over hydration must be avoided.
41. To start treatment:
give oxygen
give sterile 10% glucose (5 ml/kg) by IV
give IV fluid at 15 ml/kg over 1 hour. Use Ringer’s lactate with 5%dextrose;
or half-normal saline with 5% dextrose; or half- strength Darrow’s
solution with 5% dextrose; or if these are unavailable, Ringer’s lactate
measure and record pulse and respiration rates every 10 minutes
give antibiotics
42. If there are signs of improvement (pulse and respiration
rates fall):
repeat IV 15 ml/kg over 1 hour; then
• switch to oral or nasogastric rehydration with ReSoMal, 10 ml/kg/h for up to
10 hours.
(Leave IV in place in case required again);
Give ReSoMal in alternate hours with starter F-75, then
• continue feeding with starter F-75
43. If the child fails to improve
after the first hour of treatment (15 ml/kg),
assume that the child has septic shock. In this case:
give maintenance IV fluids (4 ml/kg/h) while waiting for blood,
when blood is available transfuse fresh whole blood at 10 ml/kg slowly
over 3 hours; then
begin feeding with starter F-75
44. If the child gets worse
during treatment (breathing increases by 5 breaths
or more/min and pulse increases by 25 or more beats/min):
stop the infusion to prevent the child’s condition worsening
45. C. TREATMENT OF ASSOCIATED CONDITIONS
1.Vitamin A Deficiency-Single dose, if not received in previous one month
Don’t give Vitamin A in case of edema.
Xerophthalmia
Age Dose
6-12 months 100,000 i.u
1-5 Years 200,000 i.u
46. If there is corneal clouding or ulceration,
give additional eye care to prevent extrusion of the lens:
instill chloramphenicol or tetracycline eye drops (1%) 2-3 hourly as
required for 7-10 days in the affected eye
- instill atropine eye drops (1%), 1 drop three times daily for 3-5 days
-cover with eye pads soaked in saline solution and bandage
Note: children with vitamin A deficiency are likely to be photophobic and
have closed eyes.
It is important to examine the eyes very gently to prevent rupture.
47. 2. Severe anemia in malnourished children
A blood transfusion is required if:
• Hb is less than 4 g/dl OR
• if there is respiratory distress and Hb is between 4 and 6 g/dl
Give:
• whole blood 10 ml/kg body weight slowly over 3 hours
• furosemide 1 mg/kg IV at the start of the transfusion
It is particularly important that the volume of 10 ml/kg is not
exceeded in severely malnourished children.
If the severely anemic child has signs of cardiac failure,
transfuse packed cells (5-7 ml/kg) rather than whole blood.
49. Monitor for signs of transfusion reactions
If any of the following signs develop
during the transfusion, stop the transfusion:
• fever
• itchy rash
• dark red urine
• confusion
• shock
50. Blood Transfusion
Also monitor the respiratory rate and pulse rate every 15 minutes. If either
of them rises, transfuse more slowly. Following the transfusion, if the Hb
remains less than 4 g/dl or between 4 and 6 g/dl in a child with continuing
respiratory distress,
DO NOT repeat the transfusion within 4 days. In mild or moderate anemia, oral
iron should be given for two months to replenish iron stores
BUT this should not be started until the child has begun to gain weight.
51. 3. Dermatosis
Signs:
• hypo-or hyperpigmentation
• desquamation
• ulceration (spreading over limbs, thighs, genitalia, groin, and behind
the ears)
• exudative lesions (resembling severe burns) often with secondary
infection, including Candida
Zinc deficiency is usual in affected children and the skin quickly
improves with zinc supplementation. In addition:
• apply barrier cream (zinc and castor oil ointment, or petroleum jelly
or paraffin gauze) to raw areas
• omit nappies so that the perineum can dry
55. 4. Parasitic Infestation
De-worming on second week(1-5 years)
-Albendazole 400mg
1 to 2 years ½ tablet single dose
>= 2years 1 tablet single dose
OR
-Mebendazole 500mg
1-2year 250mg single dose
≥2Years 500mg single dose
56. 4. Tuberculosis (TB)
If TB is strongly suspected (contacts with adult TB patient, poor growth
despite good intake, chronic cough, chest infection not responding to
antibiotics):
• perform Mantoux test (false negatives are frequent)
• chest X-ray if possible
• If test is positive or there is a strong suspicion of TB, treat according to
national TB guidelines.
• BCG diagnostic
57. D. FAILURE TO RESPOND TO TREATMENT
Failure to respond is indicated by:
1. High mortality
2. Low weight gain during the rehabilitation phase
Mortality
>20% Unacceptable
11-20% Poor
5-10% moderate
<5% Good
58. 2. Low weight gain during the rehabilitation phase
Poor: <5g/kg/d
Moderate: 5-10g/kg/d
Good: >10 g/kg/d
If weight gain is <5 g/kg/d determine:
• whether this is for all cases (need major
management overhaul)
• whether this is for specific cases (reassess child as for
a new admission)
59. Possible causes of poor weight gain are:
a) Inadequate feeding
b) Specific nutrient deficiencies
c) Untreated infection
e) Psychological problems
60. E. DISCHARGE BEFORE RECOVERY IS COMPLETE
The child
• has completed antibiotic treatment
• has good appetite and good weight gain
• has taken potassium/magnesium/mineral/vitamin supplement for 2 weeks (or
continuing supplementation at home is possible)
61. E. DISCHARGE BEFORE RECOVERY IS COMPLETE
SC.
• Clinically well, Social Smile, Appetite good and gaining weight
The mother
is not employed outside the home
is specifically trained to give appropriate feeding (type, amount and
frequency)
has the financial resources to feed the child
lives within easy reach of the hospital for urgent readmission if the child
becomes ill
can be visited weekly
is trained to give structured play therapy
is motivated to follow the advice given
62. E. DISCHARGE BEFORE RECOVERY IS COMPLETE
Local health workers
• are trained to support home care
• are specifically trained to examine the child clinically at home, to decide when to
refer him/her back to hospital, to weigh the child, and give appropriate advice
• are motivated
